1548278948 NPI number — LIBERTY HEALTHCARE GROUP, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548278948 NPI number — LIBERTY HEALTHCARE GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIBERTY HEALTHCARE GROUP, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548278948
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2334 S 41ST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28403-5502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-815-3122
Provider Business Mailing Address Fax Number:
910-815-3111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1220 21ST AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MYRTLE BEACH
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29577-7401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-839-2273
Provider Business Practice Location Address Fax Number:
843-839-2277
Provider Enumeration Date:
08/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ZIZZAMIA
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT/EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
910-815-3122

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X , with the licence number:  HPC093 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: HSP072 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 007A . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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